Abnormal Pathology Following Vaginal Hysterectomy for Pelvic Organ Prolapse Repair.

Objective: Uterine-sparing surgery for pelvic organ prolapse (POP) repair has shown good results, but the potential negative implications of leaving the uterus in place are yet to be fully defined. We aimed to assess the risk of unanticipated abnormal gynecological pathology at the time of reconstructive pelvic surgery. Methods: A retrospective consecutive case series including women who underwent vaginal hysterectomy for POP repair at a tertiary medical center in 2006-2020. All patients were offered a free Pap smear test at the age of 65 years as part of a national screening program. Transvaginal ultrasound was routinely performed preoperatively. Standard 3 pedicle hysterectomy was performed with/without bilateral salpingo-oophorectomy (BSO). Results: The study comprised 462 women of mean age 63 ± 9.3 years without previous known malignant or premalignant pathology. Benign pathology was observed in 286 patients (61.9%). Endometrial malignancy was found in three patients (0.7%) and significant premalignant pathology in 15 patients (3.2%), including cervical intraepithelial neoplasia stage 2-3 in seven patients (1.5%) and complex hyperplasia with atypia in eight patients (1.7%). All these pathologies were found in postmenopausal women. None had preoperative clinical symptoms or endometrial thickness of ≥5 mm on preoperative ultrasound. In the 35 patients after BSO, adnexal findings were normal (77.2%) or benign (22.8%). Conclusions: Premenopausal women with uterovaginal prolapse and normal preoperative evaluation have a minimal risk of significant abnormal uterine pathology. In postmenopausal women, the risk of unanticipated malignant uterine pathology is 0.7% and 3.2% for significant premalignancy.

To know or not to know: Effect of third-trimester sonographic fetal weight estimation on outcomes of large-for-gestational age neonates.

OBJECTIVE: The aim of the present study was to evaluate the impact of late third-trimester sonographic estimation of large for gestational age fetuses on pregnancy management and selected fetal and maternal adverse outcomes. METHODS: A retrospective cohort study was conducted in a tertiary, university-affiliated medical center between 2015 and 2019. All singleton large-for-gestational-age neonates born during this period were included. The cohort was divided into two groups: neonates for whom fetal weight was estimated on late third trimester (<14 days before delivery) sonography and neonates with no recent fetal weight estimation. The groups were compared for pregnancy management strategies, rates of labor induction, cesarean deliveries, and maternal and neonatal outcomes. RESULTS: A total of 1712 neonates were included in the study, among whom 791 (46.2%) had a late third-trimester fetal weight estimation (study group) and 921 (53.8%) did not (control group). Compared to the control group, the study group was characterized by higher rates of maternal primiparity (24.20% vs 19.20%, P = 0.013), higher maternal body mass index (26.0 ± 6.2 kg/m2 vs 24.7 ± 4.5 kg/m2, P = 0.002), more inductions of labor (29.84% vs 16.40%, P < 0.001) and cesarean deliveries (31.0% vs 19.97%, P < 0.001). There were no clinical differences in neonatal birth weight (4041 ± 256 g vs 3984 264 g, P < 0.001) and no significant differences between other neonatal outcomes, as rates of admission to the neonatal intensive care unit, jaundice, hypoglycemia, and shoulder dystocia. CONCLUSION: Late third-trimester sonographic fetal weight estimation is associated with a higher rate of labor induction and planned and intrapartum cesarean deliveries. In this retrospective cohort study, those interventions did not lead to reduction in maternal or neonatal adverse outcomes.

Outcome of subsequent pregnancies in women with prior uterine rupture.

OBJECTIVE: To report maternal and neonatal outcomes of subsequent pregnancies in a series of women with a prior uterine rupture. METHODS: The records of all 103,542 deliveries (22,286 by cesarean section) performed in a single tertiary medical center from 2009 to 2021 were reviewed. Women with a prior uterine rupture, defined as a separation of the entire thickness of the uterine wall, with extrusion of fetal parts and intra-amniotic contents into the peritoneal cavity documented in the operative report of the previous cesarean delivery or laparotomy, were identified for inclusion in the study. RESULTS: The cohort included 38 women with 50 pregnancies (50 neonates). Women had been scheduled for elective cesarean delivery at early term. Mean gestational age at delivery was 36 + 4 weeks (±5 days). In 7 pregnancies (14 %), spontaneous labor occurred before the scheduled cesarean delivery (at 36 + 6, 35 + 4, 35 + 3, 34 + 6, 34 + 3, 32 + 6 and 31 + 0 gestational weeks). A recurrent uterine scar rupture was found in 4 pregnancies (8 %), and uterine scar dehiscence, in 2 pregnancies (4 %), all identified during elective repeat cesarean delivery. In none of these cases was there a clinical suspicion beforehand; all had good maternal and neonatal outcomes. One parturient with placenta previa-accreta had a planned cesarean hysterectomy. CONCLUSION: Women with prior uterine rupture have good maternal and neonatal outcomes in subsequent pregnancies when managed at a tertiary medical center, with planned elective term cesarean delivery, or even earlier, at the onset of spontaneous preterm labor.

Risks of urgent cesarean delivery preceding the planned schedule: A retrospective cohort study.

PURPOSE: The aim of the study was to ascertain risk factors and outcomes of elective cesarean deliveries performed urgently prior to their scheduled date. METHODS: Women carrying a viable singleton fetus who were scheduled for elective cesarean delivery at a tertiary medical center between 2012-2020 were identified by retrospective database. Differences in maternal and neonatal parameters between those who ultimately required urgent cesarean delivery and those who underwent the procedure as scheduled were analyzed. RESULTS: Of 4403 women who met the inclusion criteria, 559 underwent urgent cesarean delivery before the scheduled date. On multivariate analysis, factors significantly associated with a risk of transformation to an urgent cesarean delivery were chronic hypertension (aOR 1.92, 95% CI 1.30-2.83 P = 0.001), antenatal corticosteroids administration (aOR 3.26, 95% CI 2.38-4.47, P <0.001), and contraindication for vaginal delivery as the reason for elective cesarean delivery (aOR 1.67, 95% CI 1.32-2.12, P <0.001). Neonates born via urgent cesareans had an increased risk of 1-minute Apgar <7 (6% vs. 1.7%, P <0.001), intensive care unit admission (6.6% vs. 2.5%, P <0.001); their mothers were at risk of postpartum hemorrhage (5.9% vs. 3%, P = 0.001). CONCLUSIONS: The present study sheds light on the risk factors and maternal and fetal morbidities associated with elective cesarean deliveries that become urgent before the originally scheduled date. Physicians should take this information into account when planning an optimal date for elective cesarean delivery.

Is There an Age Limit for a Trial of Vaginal Delivery in Nulliparous Women?

BACKGROUND: The number of nulliparous women over the age of 35 is consistently increasing, and the optimal delivery strategy is a subject of ongoing discussion. This study compares perinatal outcomes in nulliparous women aged ≥35 years undergoing a trial of labor (TOL) versus a planned cesarean delivery (CD). METHODS: A retrospective cohort study including all nulliparous women ≥ 35 years who delivered a single term fetus at a single center between 2007-2019. We compared obstetric and perinatal outcomes according to mode of delivery-TOL versus a planned CD, in three different age groups: (1) 35-37 years, (2) 38-40 years, and (3) >40 years. RESULTS: Out of 103,920 deliveries during the study period, 3034 women met the inclusion criteria. Of them, 1626 (53.59%) were 35-37 years old (group 1), 848 (27.95%) were 38-40 (group 2), and 560 (18.46%) were >40 years (group 3). TOL rates decreased as age increased: 87.7% in group 1, 79.3% in group 2, and 50.1% in group 3, p < 0.001. Rates of successful vaginal delivery were 83.4% in group 1, 79.0% in group 2, and 69.4% in group 3, p < 0.001). Neonatal outcomes were comparable between a TOL and a planned CD. Using multivariate logistic regression, maternal age was found to be independently associated with slightly increased odds for a failed TOL (aOR = 1.13, CI 95% 1.067-1.202). CONCLUSIONS: A TOL at advanced maternal age appears to be safe, with considerable success rates. As maternal age advances, there is a small additive risk of intrapartum CD.

Perinatal Outcomes after Liver Transplantation: Is There a Role for Aspirin Treatment?

BACKGROUND: We aimed to describe perinatal outcomes and evaluate aspirin treatment effects in liver-transplanted pregnant women. METHODS: A retrospective study examining perinatal outcomes in liver transplant recipients at a single center (2016-2022). The effect of low-dose aspirin treatment on the risk of developing hypertensive disease in these patients was evaluated. RESULTS: Fourteen deliveries in 11 pregnant liver transplant recipients were identified. Primary liver disease was Wilson's in 50% of pregnancies. The median age was 23 years at transplant and 30 at conception. Tacrolimus was administered in all, steroids in 10 (71.43%), and aspirin (100 mg daily) in 7 (50.0%). Overall, two women (14.28%) developed preeclampsia, and one (7.14%) developed gestational hypertension. Median gestational age at delivery was 37 weeks (31-39 weeks), with six preterm births (between 31-36 weeks) and a median birthweight of 3004 g(range 1450-4100 g). None of those receiving aspirin developed hypertensive disease or suffered excessive bleeding during pregnancy, compared to two (28.57%) with pre-eclampsia in the non-aspirin group. CONCLUSION: Liver-transplanted pregnant women comprise a unique and complex patient population with overall favorable pregnancy outcomes. Based on our single-center experience and due to its safety profile and potential benefit, we recommend low-dose aspirin in all liver transplanted patients during pregnancy for preeclampsia prevention. Further large prospective studies are needed to corroborate our findings.

Maternal and perinatal outcomes of failed prostaglandin induction of labour: A retrospective cohort study.

Background: Induction of labor is performed in up to 25% of pregnant women. When the cervix is unfavorable, cervical ripening may be safely and effectively performed using slow-release vaginal inserts of prostaglandin E2. However, the risk factors, management, and outcome of patients who fail to respond remain unclear. Objective: To evaluate the outcomes of women who fail to respond to cervical ripening with prostaglandins. Methods: A retrospective cohort analysis (2013-2019) was conducted. Women with a singleton gestation who underwent induction of labor due to post-date pregnancy using a slow-release prostaglandin E2 vaginal insert for cervical ripening were included. Data on clinical and outcome factors were derived from the medical files, and findings were compared between patients who achieved ripening within 24 h of treatment onset and those who did not. The primary outcome measure was the vaginal delivery rate following the ripening process. Secondary outcome measures were adverse composite maternal and neonatal outcomes. A model combining maternal characteristics and response rates to ripening was constructed. Results: The final cohort included 1285 women: 1202 responded to cervical ripening (93.54%) and 83 (6.46%) did not. Compared to non-responders, responders had higher rates of vaginal delivery (96.51% vs. 66.27%, P < 0.001); lower rates of adverse maternal composite outcome (12.81% vs. 24.10%, P = 0.031) and adverse neonatal composite respiratory outcome (1.33% vs. 6.02%, P = 0.009). Responders were younger than non-responders (mean 30.03 years vs 31.73 years, P = 0.005) and had a lower nulliparity rate (50.99% vs 76.92%, P < 0.001). On multivariate analysis, failure to achieve cervical ripening was an independent risk factor for intrapartum cesarean delivery due to prolonged labor (aOR 11.90, 95% CI 6.13-23.25). Conclusion: Women who achieve cervical ripening with prostaglandin E2 vaginal inserts are younger and more often multiparous than women who fail to respond. Good response to the cervical ripening process is associated with lower rates of intrapartum cesarean delivery and of adverse outcomes.

The risk of placenta accreta following primary cesarean delivery.

OBJECTIVE: To (a) evaluate the risk for placenta accreta following primary cesarean section (CS), in regard to the stage of labor, the cesarean section was taken (elective prelabor vs. unplanned during labor); and (b) investigate whether the association between placenta accreta and maternal and neonatal complications is modified by the type of the primary CS. STUDY DESIGN: In a population-based retrospective cohort study, we included all singleton deliveries occurred in Soroka University Medical Center between 1991 and 2015, of women who had a history of a single CS. The deliveries were divided into three groups according to the delivery stage the primary CS was carried out: 'Unplanned 1' (first stage-up to 10 cm), 'Unplanned 2' (second stage-10 cm) and 'Elective' prelabor CS. We assessed the association between the study group and placenta accreta using logistic generalized estimation equation (GEE) models. We additionally assessed maternal and neonatal complications associated with placenta accreta among women who had elective and unplanned CS separately. RESULTS: We included 22,036 deliveries to 13,727 women with a history of one CS, of which 0.9% (n = 207) had placenta accreta in the following pregnancies: 12% (n = 25) in the 'Unplanned 1' group, 7.2% (n = 15) in the ' Unplanned 2' group and 80.8% (n = 167) in the 'elective' group. We found no difference in the risk for subsequent placenta accreta between the groups. In a stratified analysis by the timing of the primary cesarean delivery, the risk for maternal complications, associated with placenta accreta, was more pronounced among women who had an unplanned CS (OR 27.96, P < 0.01) compared to women who had an elective cesarean delivery (OR 13.72, P < 0.01). CONCLUSIONS: The stage in which CS is performed has no influence on the risk for placenta accreta in the following pregnancies, women who had an unplanned CS are in a higher risk for placenta accrete-associated maternal complications. This should be taken into consideration while counselling women about their risk while considering trial of labor after cesarean section.